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INTRODUCTION: The role of the clinical nurse specialist is complex but is defined differently across the world. The role of clinical nurse specialist stoma care is undefined and it is uncertain what aspects of the role are included in the general day-to-day working role. AIMS: The aim was to gain consensus opinion to answer the research question: 'What is the role of the clinical nurse specialist in stoma care?' DESIGN: Delphi consensus. METHODS: Previous data gained from a scoping review and expert consultation was utilized to form role statements. At a UK conference the 13 statements and 173 sub-categories were voted upon. Consensus was agreed if 75% of voters voted agree or strongly agree. Two stages of voting occurred with results from the first vote being shared in the second voting session. RESULTS: All 13 statement and most (150/193) statement sub-categories reached consensus, with 20 sub-categories added during voting session one. CONCLUSIONS: The four pillars of advanced practice were met by the 13 statements with clinical and education reaching higher consensus and agreement than leadership/management and research. The results of the consensus study provide a clearer articulation of the clinical nurse specialist stoma care role, which is complex and multifaceted which has not been described previously. IMPLICATIONS FOR PRACTICE: Consideration of role evolution is made possible, to gain a greater expertise in the scope of practice it is necessary to include prescribing, management and research which could improve service delivery and optimize patient outcomes. There was no patient or public contribution, which in hindsight would have potentially improved the process but it was considered that patients might not recognize the full role of the nurse, understanding only aspects of the role that were patient-centred. PATIENT OR PUBLIC CONTRIBUTION: No patients or public were involved in any aspect of this paper-in hindsight this might have been useful.
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Consenso , Técnica Delphi , Enfermeras Clínicas , Rol de la Enfermera , Estomas Quirúrgicos , Humanos , Enfermeras Clínicas/normas , Reino Unido , Femenino , Masculino , Adulto , Persona de Mediana EdadRESUMEN
AIMS: Surgical treatment for inflammatory bowel disease (IBD) potentially includes stoma formation. Although positive clinical outcomes are widely reported, patients' responses to stoma surgery, including coming to terms with and adjusting to the stoma, vary widely. This scoping review charts the qualitative literature addressing the question: What is known about any personal psychosocial and quality of life factors that inform adjustment to living well with an intestinal stoma for IBD? DESIGN: A scoping review methodology was employed. DATA SOURCES: Searches of Scopus, Web of Science, CINAHL, Medline and PsycInfo in August 2023. REVIEW METHODS: Levac et al.'s (2010) methodology was followed. PRISMA-ScR guidelines were adhered to. RESULTS: Thirteen cross-sectional studies were included, involving a total of 142 participants. Four themes were identified: (1) facilitative factors; (2) barriers to adjustment; (3) personal attributes; and (4) time and temporality. Data indicate that personal and psychological factors influence adjustment, but not how this occurs. Adjustment takes longer to achieve than is conventionally (clinically) expected. CONCLUSION: All available evidence is cross-sectional. The identified gap in the evidence is the notable lack of longitudinal research to assess, monitor and understand the complex process of adjustment in people with IBD having stoma-forming surgery. Detailed understanding of the process of adjustment would enable more targeted support for patients preparing for, and learning to live with, a stoma for IBD. IMPACT: This paper highlights the need to understand the multiple personal and psychosocial factors that affect adjustment to life with a stoma and identifies that adjustment takes significantly longer than the few weeks required to become competent in managing the stoma. PATIENT OR PUBLIC CONTRIBUTION: Not applicable.
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There are many benefits of standardised care but often this is not possible due to variations in the availability of healthcare resources in the UK. Within stoma care, there is evidence to guide care but with limited standardisation, particularly for community nurses. Stoma care is provided inconsistently, possibly due to variations in training and experience of the nurse. It is known that patients have greater needs in the first few months after stoma formation and this need for support is compounded if there are stoma complications. Community nurses can provide practical support and information, as well as psychological support and encouragement to help people become independent with stoma care and adapt to life with a stoma.
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Estomas Quirúrgicos , Humanos , PacientesRESUMEN
Community nurses are often the common link with people in the community with healthcare services. Community nurses are involved in the care of people living with a temporary or permanent stoma and might be asked specialist questions of which they may feel uncertain of appropriate responses. This article describes some basic facts about stoma as well as specialist dietary considerations; which can be used to improve symptoms such as constipation as well as how to prevent issues such as a food bolus obstruction. An increased understanding of stoma-related dietary needs among community nurses will likely improve care outcomes, as they will feel more equipped to offer tailored guidance and support.
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Colostomía , Estomas Quirúrgicos , Humanos , Ileostomía , DietaRESUMEN
AIM: Low anterior resection syndrome (LARS) has a large impact on patients' quality of life. Several heterogeneous intervention pathways are suggested in the literature. The steps and timing of the different steps in the pathways are unclear. This systematic scoping review aims to map the range of intervention pathways for LARS after sphincter-saving rectal cancer surgery. METHODS: A search was undertaken on four databases (CINAHL, EMBASE, PubMed, and Web of Science). Any type of paper describing intervention pathways for patients with LARS following sphincter-saving surgery was included. Excluded were patients with a stoma, no full paper, no intervention pathway and not being written in English or Dutch. The review was registered with Open Science Framework (10.17605/OSF.IO/JB5H8). Narrative synthesis of the results was performed by charting and summarising key results. RESULTS: A total of 373 records were screened and 12 papers were included. There was a high variability among the intervention pathways, including which patients should be included. The number of pathway steps ranged from 2-6. Most intervention pathways were treatment-led. Intervention options ranged from conservative measures to a permanent stoma. Pathway flow was highly variable and sometimes not well described, with different or no timings provided for the start, progression, or end of the pathways. Three studies discussed the use of a nurse to coordinate the pathway. CONCLUSION: This systematic scoping review shows that despite similarities in treatment options there are variations in which treatments are included, when treatments should be instigated, and even which patients should be treated.
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Neoplasias del Recto , Humanos , Neoplasias del Recto/cirugía , Síndrome de Resección Anterior Baja , Complicaciones Posoperatorias , Calidad de Vida , Recto/cirugíaRESUMEN
AIM: The aim of this study was to determine the views of people on their healthcare needs when managing their bowel symptoms following an anterior resection. METHOD: One-to-one, semi-structured interviews were undertaken, after consent and completion of three questionnaires. Results were analysed using a modified framework analysis and presented narratively. RESULTS: Twenty three participants aged 38-75 years were interviewed; 10 were men. Most had low anterior resection syndrome (LARS) scores indicating 'major LARS', Bowel Function Index scores ranged from 28 to 65. The two most bothersome symptoms were faecal incontinence and unpredictable bowel function. Data were grouped into three broad themes: 'treatment consequences', 'strategies and compromises' and 'healthcare needs.' Each theme had four subthemes, such as 'bowel dysfunction' in the theme 'treatment consequences'. Bowel symptoms were common and persistent. Symptom management often required multiple interventions. Expressed healthcare needs included managing expectations through clinician-led information. Participants needed knowledgeable clinicians to enquire about and assess symptoms, provide and reiterate information as well as making an onward referral to enable symptom management. Peers improved the adaptation process through support and advice. Our findings indicate that participants' needs are not being fully met. CONCLUSION: People with LARS have unmet healthcare requirements needed to meet their individual goals. We propose these are addressed by using the acronym 'LARS': a Learned clinician who Asks and assesses bowel symptoms, Revisiting the topic to address new or persisting symptoms as well as Signposting, advising or referring onwards as needed.
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Neoplasias del Recto , Cirujanos , Masculino , Humanos , Femenino , Neoplasias del Recto/cirugía , Síndrome de Resección Anterior Baja , Complicaciones Posoperatorias/diagnóstico , Recto/cirugía , Atención a la Salud , Calidad de VidaRESUMEN
There are three main output stomas-colostomy, ileostomy and urostomy. Each of these requires a different stoma appliance to collect and contain the stoma output. This article discusses stoma product selection, things to consider before choosing a product, as well as caring for the stoma.
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Estomía , Estomas Quirúrgicos , Derivación Urinaria , Humanos , Colostomía , IleostomíaRESUMEN
AIM: Rapidly evolving roles in nursing require exploration and description. This review aims to examine the role of the clinical nurse specialist (CNS) in stoma care from the UK perspective. DESIGN: A scoping review was undertaken using the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Data were synthesised using content analysis to derive meaning units and themes. DATA SOURCES: Three electronic databases were used to conduct the search: Embase, AMED and Ovid Medline. Additional sources identified through the reference lists of included studies and guidelines were also included. METHODS: Two reviewers undertook the search for articles that described the role of the stoma care CNS in the UK. Any disagreements were to be resolved through discussion. RESULTS: Seven papers met the eligibility criteria. Analysis resulted in 184 unique meaning units. Meaning units were grouped into themes reflecting the four pillars of advanced practice: advanced clinical practice; leadership; facilitation of education and learning; and evidence, research and development. The fewest meaning units were attributed to the evidence theme (n=13) and the most related to advanced clinical practice (n=107) such as having specialist knowledge and skills to manage complications. CONCLUSION: The stoma care CNS role reflects the four pillars of advanced practice. These practitioners are valuable, carrying out a complex role that involves high-level, specialist decision-making skills. The results from this scoping review could be useful in service development; they will be used to inform the Association of Stoma Care Nurses UK modified Delphi consensus to examine the views of stoma care CNS practitioners.
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Enfermeras Clínicas , Humanos , Consenso , Bases de Datos Factuales , Conocimiento , LiderazgoRESUMEN
With 205 000 people in the UK with a stoma, it is likely that community nurses will need to consider which stoma products are most appropriate to use with this group of patients. This article explores the three output stomas, what stoma appliances are most commonly used for each type of stoma and why. Understanding how often stoma appliances should be changed empowers the community nurse in their decision-making process to ascertain whether changes to current care are needed. There is also information available about some of the more commonly used stoma accessories and when these may be necessary. With so many stoma-related products available, it can be difficult to know what to use and when; therefore, this article seeks to offer data to aid stoma care in the community.
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Estomía , Estomas Quirúrgicos , Humanos , Encuestas y CuestionariosRESUMEN
Community nurses will have people with a stoma on their caseload, and a reminder about stoma and stoma care will hopefully increase confidence and, subsequently, care. There are approximately 205 000 people in the UK with a stoma; it is a common condition, with approximately one in every 340 people having a stoma. While quality of life with a stoma can be good, problems can occur, such as a leaking appliance that results in skin damage. Skin damage can occur for all people with a stoma, but is more common for people with an ileostomy. Appliance leakage can increase stoma care costs, time, financially as well as a decrease in quality of life, so it is important to be able to address issues when they arise or refer on as necessary.
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Calidad de Vida , Estomas Quirúrgicos , Humanos , IleostomíaRESUMEN
In the community there are about 200 000 people with a stoma. Some of these may have been performed as a palliative procedure to relieve a bowel obstruction, for example. Alternatively, the condition of the patient may have altered. A person with a stoma may, for many reasons, be approaching the end of life. There are a number of stoma-related issues that can occur at the end of life as a result of cancer treatment, such as skin around the stoma being damaged as a result of chemotherapy or changes in weight. In the palliative setting, patients may no longer be able to independently care for their stoma and may require assistance from the community nurse. Input from the community nurse may include information on changing stool consistency, as a result of disease progression or cancer treatment. Alternatively, nursing input might be necessary to train carers to perform stoma care. Community nurses can also provide knowledge to patients to improve understanding and decrease anxiety at the end of life.
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Enfermería en Salud Comunitaria , Cuidados Paliativos , Cuidados de la Piel/enfermería , Estomas Quirúrgicos , Humanos , Enfermeros de Salud Comunitaria , Cuidados Posoperatorios , Especialidades de EnfermeríaRESUMEN
The functions of the lower parts of the bowel, namely the colon and rectum, are predominantly the absorption of fluids and elimination of faeces and flatus. Bowel surgery may be carried out in the treatment of colorectal cancer, inflammatory bowel disease or diverticular disease, and may involve the formation of a permanent or temporary stoma. The type of colorectal surgery carried out depends on the condition and where the problem occurs. Surgery can alter not only the bowel's anatomy but also its functioning. Bowel dysfunction can manifest as constipation, faecal incontinence or diarrhoea. Nurses are well placed to assist patients to resolve many of these problems as well as stoma issues.
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Enfermedades Gastrointestinales , Complicaciones Posoperatorias , Enfermedades Gastrointestinales/enfermería , Humanos , Complicaciones Posoperatorias/enfermeríaRESUMEN
One of the biggest challenges for specialist stoma care nurses (SCNs) caring for anyone living with a stoma is that of being confronted with a problematic stoma. This can be described as an ostomy that continues to cause leakage issues for the patient which, if persistent can quickly impact negatively on their quality of life. A convex stoma appliance, also termed convexity, is a possible solution to a problematic stoma. However, the use of a convex appliance should be considered only after a thorough assessment has been undertaken by a specialist SCN. Professionally, stoma care nursing has advanced greatly in recent years and there has been a realisation that there is a need for clinical guidelines to direct practice and offer a process for the novice SCN to follow. This realisation has been the catalyst behind the development of the new guideline for the assessment and use of convexity by the Association of Stoma Care Nurses UK, which was published this year (https://ascnuk.com/). This article explores the concept of convexity and how the guideline can assist the practice of specialist SCNs, as well as that of ward and community-based nurses who wish to gain more information on using convexity within the specialist sphere of stoma care.
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Enfermeras Clínicas , Estomía , Estomas Quirúrgicos , Humanos , Calidad de Vida , Reino UnidoRESUMEN
Jennie Burch, Head of Gastrointestinal Nurse Education, St Mark's Hospital, London (jburch1@nhs.net), discusses the ramifications of coronavirus and the guidelines available to professionals working in gastroenterology.
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Infecciones por Coronavirus/enfermería , Gastroenterología , Neumonía Viral/enfermería , Especialidades de Enfermería , COVID-19 , Humanos , Pandemias , Guías de Práctica Clínica como AsuntoRESUMEN
The gastrointestinal (GI) tract has a number of functions-ingestion, digestion, absorption and elimination. When the GI tract is working normally, it is efficient. However, this can change when disease, such as inflammatory bowel disease (IBD) occurs. IBD is a long-term relapsing and remitting autoimmune disease; it incorporates ulcerative colitis (UC). In UC, part or all the mucosa lining the rectum and colon becomes inflamed and ulcerated. UC that affects the rectum only is called proctitis. Effective treatment is essential. It is better to target the rectal mucosa directly in proctitis, using topical rectal medications in enemas or suppositories, as these have fewer side-effects and resolve symptoms more quickly than systemic drugs. However, patients may not feel clear about aspects of their IBD care and can find it difficult to initiate and comply with treatment and maintenance regimens. Nurses need to educate and support them to achieve optimal therapeutic outcomes in both the immediate and long terms.
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Colitis Ulcerosa , Proctitis , Colitis Ulcerosa/tratamiento farmacológico , Humanos , Cumplimiento de la Medicación , Proctitis/tratamiento farmacológico , Recto , SupositoriosRESUMEN
Lesley Dibley, Reader in Nursing Research and Education, University of Greenwich (L.B.Dibley@greenwich.ac.uk), and Jennie Burch, Head of Gastrointestinal Nurse Education, St Mark's Hospital, outline the need to assess patients' emotional as well as physical needs before stoma surgery for IBD.
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Adaptación Psicológica , Enfermedades Inflamatorias del Intestino/cirugía , Estomas Quirúrgicos , Investigación Biomédica , Predicción , Humanos , Enfermedades Inflamatorias del Intestino/enfermeríaRESUMEN
BACKGROUND: Enhanced Recovery After Surgery (ERAS) is widely accepted in current surgical practice due to its positive impact on patient outcomes. The successful implementation of ERAS is challenging and compliance with protocols varies widely. Continual staff education is essential for successful ERAS programmes. Teaching modalities exist, but there remains no agreement regarding the optimal training curriculum or how its effectiveness is assessed. We aimed to draw consensus from an expert panel regarding the successful training and implementation of ERAS. METHODS: A modified Delphi technique was used; three rounds of questionnaires were sent to 58 selected international experts from 11 countries across multiple ERAS specialities and multidisciplinary teams (MDT) between January 2016 and February 2017. We interrogated opinion regarding four topics: (1) the components of a training curriculum and the structure of training courses; (2) the optimal framework for successful implementation and audit of ERAS including a guide for data collection; (3) a framework to assess the effectiveness of training; (4) criteria to define ERAS training centres of excellence. RESULTS: An ERAS training course must cover the evidence-based principles of ERAS with team-oriented training. Successful implementation requires strong leadership, an ERAS facilitator and an effective MDT. Effectiveness of training can be measured by improved compliance. A training centre of excellence should show a willingness to teach and demonstrable team working. CONCLUSIONS: We propose an international expert consensus providing an ERAS training curriculum, a framework for successful implementation, methods for assessing effectiveness of training and a definition of ERAS training centres of excellence.
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Técnica Delphi , Educación Continua , Atención Perioperativa/métodos , Consenso , Curriculum , Humanos , Complicaciones Posoperatorias/prevención & control , Recuperación de la FunciónRESUMEN
Marking the optimal position for a stoma on the patient's body before an operation is likely to result in fewer postoperative problems such as appliance leakage. A literature search was undertaken to examine and evaluate current practice internationally. Four recent articles describe the procedure; these articles were consensus documents or expert opinion, with limited robust research to support the statements made. Despite some variations in techniques, there was general agreement within the articles. Interestingly, when comparing recent and historical information on stoma siting, there were reassuringly few changes. Thus, in practice, although poorly researched, it is considered essential for people to have their stoma site marked as part of their preoperative preparation before elective stoma-forming surgery.